Retailers Credit Application

Contact Information

Email Address

Value is required

Name

Job Title

Company

Business Information as registered

Company Name

Company Address

City

State

Postcode

Company Phone Number

Length of stay in current address (year/s & month/s)

Bank Information

Bank name

Account name

Contact number

Address

City

State

Postcode

Account number

Business References

Company #1

Contact name

Job title

Phone number

Email address

City

State

Postcode

Comments

Company #2

Contact name

Job title

Phone number

Email address

City

State

Postcode

Comments

Company #3

Contact name

Job title

Phone number

Email address

City

State

Postcode

Comments

Company #4

Contact name

Job title

Phone number

Email address

City

State

Postcode

Comments

Credit Agreement

1. All invoices must be paid within 14 days of delivery.
2. Any claims regarding an invoice issued must be made within 7 days of the date issued.
3. You authorise inquiry into the banking and business references provided within this application.

Company Representative

Your name

Your job title

Your signature

Date today

Notes and comments

Thank you!

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